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Chronic Obstructive Pulmonary Disease (COPD) – Reading & Sharing

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States.

Conventional COPD treatments:

  • Inhaled therapy
    • Inhaled bronchodilator therapy: metered-dose inhalers and spacers, dry powder inhalers, or wet nebulizers
    • Inhaler technique should be assessed to ensure that a patient is able to use a device effectively.
    • The combination of a long-acting anticholinergic with an as-needed short-acting beta-agonist is a standard initial approach.
    • For many patients with advanced COPD, the addition of a combination inhaler containing a long-acting beta-agonist and an inhaled corticosteroid to a long-acting anticholinergic agent provides benefit in terms of symptom management and quality of life.
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All About Nursing · CNE self study · Hospice & Palliative Care · Nursing Continue Education

Death Rattle and Anticholinergic Medications

Death rattle – as patients near death, they are unable to cough to clear secretions that begin to pool in the oropharynx and bronchi, resulting in rales (“death rattles”). Because the sound is often distressing to family members, an anticholinergic (glycopyrrolate or atropine) may be given subcutaneously to relieve respiratory distress. A hyoscine hydrobromide transdermal patch is also available, but action is slower, 12 hours compared to 1 minute for injections. Risks associated with anticholinergics include xerostomia (dry mouth), increased sedation, and increased delirium. Elevating the head of the bed or turning the patient to the side may also relieve rattling. Patients normally stop taking fluids as they near death, resulting in dehydration and drying of the mucous membranes of the mouth. The death rattle also begins to lessen.

Palliative care is a form of specialized medical care which aims to optimize the quality of life and alleviate the suffering of patients through early identification and treatment of new symptoms along with management of those that prove refractory.

Excessive secretions can cause the frequently noted ” death rattle” in patients that are actively dying. This is caused by relaxation of the oropharyngeal muscles leading to a pooling of secretion in the throat. While it is typically not distressing for the patient, it does often make family members and other visitors uncomfortable. Anticholinergic agents, especially sublingual atropine drops, can be administered to assist in secretion reduction. Anticholinergic agents have multiple side effects, including decreased/ absent bowel sounds, decreased sweating, hot skin, and mydriatic pupils (dilated pupils).

All About Nursing · Hospice & Palliative Care

Hypercalcemia at the End of Life

  • Hypercalcemia is associated with several cancers, most commonly breast, lung, lymphoma, and multiple myeloma. Hypercalcemia in the setting of advanced cancer may be caused by release of calcium due to bone metastases, solid tumor release of PTHrP (parathyroid hormone-related protein), or tumor production of calcitriol leading to increased intestinal calcium resorption. Hypercalcemia in cancer patients is indicative of widespread disease and is associated with a poor prognosis for long-term survival.
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CNE self study · Hospice & Palliative Care

What is POLST?

POLST is a physician order for life-sustaining treatment, which is called a medical order for life-sustaining treatment in some states. This form is created during a conversation with a medical provider and lays out the patient’s end-of-life wishes. It is considered a medical order, and is most useful in times of emergency. Typically, POLST or MOLST forms are intended for patients who have a life expectancy of 1 year or less, and the POLST is a doctor’s order for the specific instructions the patient has given the physician about what to do in possible future situations.

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All About Nursing · Hospice & Palliative Care

Determining Prognosis: Patients with Malignant Diseases (Reading & Sharing)

Cancer refers to a group of diseases that are characterized by genetic mutations in normal cells that cause them to become malignant. These genetic mutations involve the following:

      • Oncogenes, which are mutant genes that regulate cell proliferation. Oncogenes allow accelerated proliferation of the mutated cells, resulting in the rapid growth of cancerous tumors. 
      • tumor suppressor genes, which impede cell proliferation and suppress or prevent cell mutations. Cancer involves inactivation of tumor suppressor genes, allowing replication of mutated cells. 

In the TNM system: Cancer patients who require hospice or palliative care generally suffer from advanced disease, which is defined as metastatic spread of the malignancy from the primary site to other areas of the body and/or massive tumor growth at the primary site. The staging of tumors commonly follows the primary tumor, lymph node, and metastasis (TNM) system. 

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